Case Report
Edras Samuel Hernandez Musus
Hospital General de Enfermedades, Instituto Guatemalteco de Seguridad Social; Universidad de San Carlos de Guatemala. Endoscopy: Edras Samuel Hernandez Musus, Nadhikrishna Samayoa Gonzalez, Luis Fernando Sandoval Garcia, Dania Anaberta Campos Garcia, Carlos Paredes Amenabar. Pathology: Julia Milagro Ovalle Quinonez, Lizza Daniela Paz Garcia.
Figure 1 · Colonoscopy, ileocecal region
Figure 2 · CD10/Ki-67 immunohistochemistry
Figure 3 · Baseline staging PET/CT, coronal
Coronal CT, PET, and fused PET/CT from the baseline staging plate.
Experienced teaching points
Clinical Pearls
01An exophytic, lobulated ileocecal mass should prompt lymphoma in the differential. Do not treat it automatically as adenocarcinoma.
02Adequate targeted biopsies can establish the diagnosis before definitive treatment planning.
03This lesion arose from the ileocecal valve. The remaining examined colonic mucosa was unremarkable.
04Once the report is DLBCL, refer to Hematology. This patient received six cycles of R-CHOP. Follow-up PET/CT was consistent with a complete metabolic response.
Get cases like this Saturday mornings. Free on The Practicing Endoscopist.
Final Diagnosis
Ileocecal-valve diffuse large B-cell lymphoma (DLBCL), germinal-center phenotype, without a double-expressor phenotype.
Clinical History
A 63-year-old man with no relevant comorbidities presented with 6 months of generalized abdominal pain, a 25-lb unintentional weight loss, and nocturnal fever. Labs showed microcytic hypochromic anemia with hemoglobin of 10.4 g/dL, low serum iron, and elevated lactate dehydrogenase of 490 U/L. Contrast-enhanced abdominal CT showed an infiltrative mass involving the cecum and right colon, with extrinsic ureteral compression and right hydronephrosis. The appearance was concerning for an ileocecal malignancy. Lymphoma stayed on the differential.
Endoscopic Findings
- A large exophytic, endoluminal lesion arising from the ileocecal valve.
- An irregular, lobulated surface with marked distortion of the local anatomy.
- The remaining examined colonic mucosa was unremarkable.
Pathology
Histopathology showed infiltration of the lamina propria by medium-to-large atypical lymphoid cells. Immunohistochemistry was positive for CD20 and supported a germinal-center phenotype. CD10 expression and Ki-67 nuclear labeling were also demonstrated. The findings established DLBCL without a double-expressor phenotype.
Staging
Baseline PET/CT demonstrated metabolically active thickening of the cecal/ileocecal region.
Endoscopic Technique
Colonoscopy with multiple targeted biopsies of the ileocecal-valve lesion.
Discussion
Mechanism. Colorectal lymphoma may involve the ileocecal region and can present with a polypoid or mass-like morphology. A lobulated, exophytic ileocecal mass can look like adenocarcinoma until histology names it.
What the scope shows. Panels A and B are the colonoscopic lesion: exophytic, endoluminal, arising from the ileocecal valve, irregular and lobulated, with local anatomic distortion. The rest of the examined colon was unremarkable. Baseline PET/CT then showed metabolically active cecal/ileocecal wall thickening.
Why it matters clinically. Careful inspection and adequate targeted biopsies can establish DLBCL before definitive treatment planning. This patient was referred to Hematology and received six cycles of R-CHOP. Follow-up PET/CT showed disappearance of the previously hypermetabolic intestinal lesions, consistent with a complete metabolic response.
References
- Yachida T, Matsuda T, Sakamoto T, et al. Endoscopic features of colorectal lymphoma according to histological type. JGH Open. 2022;6(4):257-262.
- Vetro C, Romano A, Amico I, et al. Endoscopic features of gastro-intestinal lymphomas: from diagnosis to follow-up. World J Gastroenterol. 2014;20(36):12993-13005.
- Lightner AL, Shannon E, Gibbons MM, Russell MM. Primary gastrointestinal non-Hodgkin’s lymphoma of the small and large intestines: a systematic review. J Gastrointest Surg. 2016;20(4):827-839.
For your teaching file
Save this case as a PDF
Opens the companion page on The Practicing Endoscopist.
